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A Novel Method (Pilocarpine Iontophoresis) for Evaluation and Treatment (Omalizumab) in a case of Severe Refractory Cholinergic Urticaria
S106 Abstracts
399
SUNDAY
Increased Pollen Sensitization In Patients With Chronic Urticaria J. S. Collins; Albert Einstein School Of Medicine/Montefiore Medical Center, Bronx, NY. RATIONALE: There is substantial cross-reactivity between pollens and unrecognized food ingredients, such as spices, which often trigger hives. We measured the prevalence of pollen allergy in patients with chronic urticaria and respiratory disease (asthma and/or rhinitis) (CU) in comparison to only respiratory disease (RD). METHODS: We conducted a retrospective chart review of patients seen in our Bronx, NY outpatient allergy service, from March 2006 - July 2008, surveying for the 1) diagnosis of CU with respiratory allergic diseases, or only respiratory allergic diseases and 2) documented skin prick testing (SPT) to seven environmental allergens. RESULTS: A total of 170 patients were eligible (CU n 5 12, RD n 5 158). The most significant finding was in patients highly sensitive to birch pollen. Forty-two % (5/12) of CU patients were allergic to birch pollen compared to only 16% (26/158) RD patients (p 5 0.05). There was also a trend toward increased mugwort allergy in the CU patients. Fifty % (6/12) of CU patients were mugwort allergic compared to 27% (42/158) of RD patients (p 5 0.10). In contrast, there was no significant difference in SPT to cat, cockroach, ragweed, mite, and mouse. The proportion of positive SPT was not statistically different between groups. DISCUSSION: Pollen hypersensitivity is increased in patients with CU with concomitant respiratory disease. In this subgroup of patients, pollen sensitization may play a role in triggering CU through cross-reactivity from spices and other aromatic compounds.
400
Cinryzeä Replacement Therapy in Hereditary Angioedema and Pregnancy J. W. Baker1, A. Sheffer2, J. Christensen3, D. Hurewitz4, R. Lazar5, I. Kalfus6, A. Banerji7; 1Allergy, Asthma and Dermatology Research Center, Lake Oswego, OR, 2Brigham and Women’s Hospital Harvard Medical School, Boston, MA, 3Nevada Access to Research & Education Society, Las Vegas, NV, 4Allergy Clinic of Tulsa, Tulsa, OK, 5Grand Traverse Allergy, Traverse City, MA, 6Lev Pharmaceuticals, New York, NY, 7Massachusetts General Hospital Harvard Medical School, Boston, MA. RATIONALE: Pregnancy may increase the number and severity of hereditary angioedema (HAE) attacks. Current therapies available in the United States are mainly contraindicated or should be used with caution. Severe angioedema attacks in pregnant women may be prevented with C1 inhibitor replacement therapy. METHODS: Six patients received 1000U of Cinryze (C1 inhibitor-nf) replacement therapy 1-2 times per week as prophylaxis of HAE attacks during pregnancy. An additional patient received Cinryze 1000U immediately prior to delivery and again two days later. Data on frequency of HAE attacks and number of emergency medical visits prior to and following initiation of Cinryze replacement therapy were gathered. Side effects were monitored . RESULTS: Six of the pregnant women had normal healthy deliveries and the seventh, currently in her second trimester, remains on Cinryze. No patient treated with Cinryze replacement therapy suffered HAE related complications during her pregnancy. Number of attacks and number of emergency medical visits were reduced by >85%. No adverse events secondary to Cinryze were reported. CONCLUSIONS: Cinryze replacement therapy is a safe and effective treatment of HAE in pregnancy and should be considered as part of the standard of care during pregnancy and delivery for patients with HAE.
J ALLERGY CLIN IMMUNOL FEBRUARY 2009
401
A Novel Method (Pilocarpine Iontophoresis) for Evaluation and Treatment (Omalizumab) in a case of Severe Refractory Cholinergic Urticaria H. F. Otto, C. W. Calabria; Wilford Hall Medical Center, Lackland AFB, TX. RATIONALE: In cholinergic urticaria (CU), the diagnosis often depends on demonstration of characteristic urticaria by appropriate provocation. Although antihistamines generally control symptoms, subsets of patients are refractory to therapy. Demonstration of immediate hypersensitivity to autologous sweat skin testing (ASwST) may provide a rationale for use of omalizumab in these severe CU patients (Xolair, Genentech Novartis, San Francisco, CA). However, producing sufficient sweat for ASwST can also exacerbate the CU. Therefore, we sought a novel method of sweat collection for ASwST. METHODS: Generation of sweat by iontophoresis with pilocarpine nitrate is simple, safe and can be performed at many large medical centers. Pilocarpine iontophoresis was performed on a 25 year old female with severe CU refractory to multiple medications. ASwST was completed with 0.01 mL of autologous sweat diluted 1:1 with saline and injected intradermally. RESULTS: Our patient had a positive ASwST (wheal 12 x 12, flare 55 x 60 mm) with appropriate positive and negative controls. Our testing methods were validated by negative ASwST, saline control and positive histamine control in a non-atopic control patient. By the patient’s second injection of omalizumab, her quality of life score, daily medication scores and exercise tolerance were all significantly improved. CONCLUSIONS: We describe the first case of a patient with severe refractory CU who had a positive ASwST by a novel collection method who has been successfully treated with omalizumab. We present a novel tool for the evaluation and demonstration of sweat-specific IgE in CU patients who are unable to provide sweat by more traditional means.
402
Determination of Autologus Serum Skin Test and its Association with Clinical and Immunological Markers in Adult Patients with Chronic Urticaria Treated at the Regional Unit of Immunology at the "Dr. Enrique Tejera" Hospital from April to September 2007. M. E. Flores Cha´vez1, A. Chacon1, M. R. Chacon de Petrola2, M. T. Pacheco de Toro1; 1INSALUD, Valencia, Venezuela, 2Universidad de Carabobo, Valencia, VENEZUELA. RATIONALE: Urticaria is a common clinical entity, is called Chronic Urticaria (CU) if the clinic persists for more than 6 weeks. In those patients who were identified a positive Autologus Serum Skin Test (ASST), it was proposed the term Chronic Autoimmune Urticaria (CAU), describing in them a greater relationship with other autoimmune phenomena. METHODS: We studied 30 consecutive adult patients (Relationship Male: Female 6:24, average age: 30.3 6 8.9), with diagnosed of CU, who came to the Regional Unit of Immunology at the "Dr. Enrique Tejera’’ Hospital. A sample of blood was taken for it’s use in the determination of ASST and measurements of Complement (C3, C4 and CH50), immunoglobulin E (IgE), antithyroid antibodies (Anti-microsomal and anti-thyroglobulin) and Antinuclear antibodies (ANA). The Student’s t test, chi-square and Fisher’s Exact Test were used as necessary; P values <0.05 were considered statistically significant. RESULTS: 40% of the cases presented a positive ASST. The partnership between ASST and Anti-microsomal antibodies was significant (p 5 0.009). There was no association between the determination of ASST and clinical findings or the others immunological markers studied (P values> 0.05). CONCLUSIONS: In this study 40% of the CU cases correspond to CAU. A positive ASST is associated with positive Anti-microsomal antibodies.
399
SUNDAY
Increased Pollen Sensitization In Patients With Chronic Urticaria J. S. Collins; Albert Einstein School Of Medicine/Montefiore Medical Center, Bronx, NY. RATIONALE: There is substantial cross-reactivity between pollens and unrecognized food ingredients, such as spices, which often trigger hives. We measured the prevalence of pollen allergy in patients with chronic urticaria and respiratory disease (asthma and/or rhinitis) (CU) in comparison to only respiratory disease (RD). METHODS: We conducted a retrospective chart review of patients seen in our Bronx, NY outpatient allergy service, from March 2006 - July 2008, surveying for the 1) diagnosis of CU with respiratory allergic diseases, or only respiratory allergic diseases and 2) documented skin prick testing (SPT) to seven environmental allergens. RESULTS: A total of 170 patients were eligible (CU n 5 12, RD n 5 158). The most significant finding was in patients highly sensitive to birch pollen. Forty-two % (5/12) of CU patients were allergic to birch pollen compared to only 16% (26/158) RD patients (p 5 0.05). There was also a trend toward increased mugwort allergy in the CU patients. Fifty % (6/12) of CU patients were mugwort allergic compared to 27% (42/158) of RD patients (p 5 0.10). In contrast, there was no significant difference in SPT to cat, cockroach, ragweed, mite, and mouse. The proportion of positive SPT was not statistically different between groups. DISCUSSION: Pollen hypersensitivity is increased in patients with CU with concomitant respiratory disease. In this subgroup of patients, pollen sensitization may play a role in triggering CU through cross-reactivity from spices and other aromatic compounds.
400
Cinryzeä Replacement Therapy in Hereditary Angioedema and Pregnancy J. W. Baker1, A. Sheffer2, J. Christensen3, D. Hurewitz4, R. Lazar5, I. Kalfus6, A. Banerji7; 1Allergy, Asthma and Dermatology Research Center, Lake Oswego, OR, 2Brigham and Women’s Hospital Harvard Medical School, Boston, MA, 3Nevada Access to Research & Education Society, Las Vegas, NV, 4Allergy Clinic of Tulsa, Tulsa, OK, 5Grand Traverse Allergy, Traverse City, MA, 6Lev Pharmaceuticals, New York, NY, 7Massachusetts General Hospital Harvard Medical School, Boston, MA. RATIONALE: Pregnancy may increase the number and severity of hereditary angioedema (HAE) attacks. Current therapies available in the United States are mainly contraindicated or should be used with caution. Severe angioedema attacks in pregnant women may be prevented with C1 inhibitor replacement therapy. METHODS: Six patients received 1000U of Cinryze (C1 inhibitor-nf) replacement therapy 1-2 times per week as prophylaxis of HAE attacks during pregnancy. An additional patient received Cinryze 1000U immediately prior to delivery and again two days later. Data on frequency of HAE attacks and number of emergency medical visits prior to and following initiation of Cinryze replacement therapy were gathered. Side effects were monitored . RESULTS: Six of the pregnant women had normal healthy deliveries and the seventh, currently in her second trimester, remains on Cinryze. No patient treated with Cinryze replacement therapy suffered HAE related complications during her pregnancy. Number of attacks and number of emergency medical visits were reduced by >85%. No adverse events secondary to Cinryze were reported. CONCLUSIONS: Cinryze replacement therapy is a safe and effective treatment of HAE in pregnancy and should be considered as part of the standard of care during pregnancy and delivery for patients with HAE.
J ALLERGY CLIN IMMUNOL FEBRUARY 2009
401
A Novel Method (Pilocarpine Iontophoresis) for Evaluation and Treatment (Omalizumab) in a case of Severe Refractory Cholinergic Urticaria H. F. Otto, C. W. Calabria; Wilford Hall Medical Center, Lackland AFB, TX. RATIONALE: In cholinergic urticaria (CU), the diagnosis often depends on demonstration of characteristic urticaria by appropriate provocation. Although antihistamines generally control symptoms, subsets of patients are refractory to therapy. Demonstration of immediate hypersensitivity to autologous sweat skin testing (ASwST) may provide a rationale for use of omalizumab in these severe CU patients (Xolair, Genentech Novartis, San Francisco, CA). However, producing sufficient sweat for ASwST can also exacerbate the CU. Therefore, we sought a novel method of sweat collection for ASwST. METHODS: Generation of sweat by iontophoresis with pilocarpine nitrate is simple, safe and can be performed at many large medical centers. Pilocarpine iontophoresis was performed on a 25 year old female with severe CU refractory to multiple medications. ASwST was completed with 0.01 mL of autologous sweat diluted 1:1 with saline and injected intradermally. RESULTS: Our patient had a positive ASwST (wheal 12 x 12, flare 55 x 60 mm) with appropriate positive and negative controls. Our testing methods were validated by negative ASwST, saline control and positive histamine control in a non-atopic control patient. By the patient’s second injection of omalizumab, her quality of life score, daily medication scores and exercise tolerance were all significantly improved. CONCLUSIONS: We describe the first case of a patient with severe refractory CU who had a positive ASwST by a novel collection method who has been successfully treated with omalizumab. We present a novel tool for the evaluation and demonstration of sweat-specific IgE in CU patients who are unable to provide sweat by more traditional means.
402
Determination of Autologus Serum Skin Test and its Association with Clinical and Immunological Markers in Adult Patients with Chronic Urticaria Treated at the Regional Unit of Immunology at the "Dr. Enrique Tejera" Hospital from April to September 2007. M. E. Flores Cha´vez1, A. Chacon1, M. R. Chacon de Petrola2, M. T. Pacheco de Toro1; 1INSALUD, Valencia, Venezuela, 2Universidad de Carabobo, Valencia, VENEZUELA. RATIONALE: Urticaria is a common clinical entity, is called Chronic Urticaria (CU) if the clinic persists for more than 6 weeks. In those patients who were identified a positive Autologus Serum Skin Test (ASST), it was proposed the term Chronic Autoimmune Urticaria (CAU), describing in them a greater relationship with other autoimmune phenomena. METHODS: We studied 30 consecutive adult patients (Relationship Male: Female 6:24, average age: 30.3 6 8.9), with diagnosed of CU, who came to the Regional Unit of Immunology at the "Dr. Enrique Tejera’’ Hospital. A sample of blood was taken for it’s use in the determination of ASST and measurements of Complement (C3, C4 and CH50), immunoglobulin E (IgE), antithyroid antibodies (Anti-microsomal and anti-thyroglobulin) and Antinuclear antibodies (ANA). The Student’s t test, chi-square and Fisher’s Exact Test were used as necessary; P values <0.05 were considered statistically significant. RESULTS: 40% of the cases presented a positive ASST. The partnership between ASST and Anti-microsomal antibodies was significant (p 5 0.009). There was no association between the determination of ASST and clinical findings or the others immunological markers studied (P values> 0.05). CONCLUSIONS: In this study 40% of the CU cases correspond to CAU. A positive ASST is associated with positive Anti-microsomal antibodies.